Sexual frames within the family planning field
Jenny A. Higgins
Although family planning methods are expressly designed for use during sex, we know stunningly little about how contraceptive use affects sexual experiences and processes. As individuals, we tend to think of sex’s potential for pleasure, for forming relationships and for building individual identities. However, as Kirsten Moore and Judith Helzner have argued, professional roles as family planning researchers and practitioners may demand that we instead tend to focus on the ‘risk’ and ‘threat’ of unwanted pregnancy, disease or sexual violence (Moore and Helzner 1996). Rather than presenting sex as a potentially enjoyable, affirming or generative experience, family planning discourse portrays sex at best as the sanitised ‘exposure to the risk of conception’1 or, at worst, the cause of unfortunate outcomes such as violence, STIs or unintended pregnancy (Dixon-Mueller 1993b). This tendency to de-emphasise sexual pleasure, desire and enjoyment is especially strong when it comes to women, toward whom family planning efforts are disproportionately directed.
In this chapter, I will further illustrate the sexually sanitised framework used within contemporary family planning research and programming, providing examples and suggesting some of the limitations and double standards of this framework. I also overview some of the well-intentioned causes of this ‘pleasure deficit’ (Higgins and Hirsch 2007). Perhaps surprisingly, roots reach back to the early feminist birth control movement and extend through far more recent international women’s rights advocacy. In concluding, I suggest some possible reframings of sexuality within the field, drawing on some encouraging new research to light our way.
Before providing some examples of the field’s de-eroticised approach to sexuality, I want to define what I mean by ‘family planning’. For the purposes of this chapter, my own definition closely resembles the one first advocated by Margaret Sanger and her pro-birth control compatriots in the early twentieth century – that is, the practice in which couples together, and sometimes women or men singly, have (or prevent having) the precise number of children they want, and when. Avoiding unplanned pregnancies is achieved in large part through the use of a vast array of available contraceptive methods, from hormone-based methods such as the pill or the patch, to barrier methods such as male and female condoms, to sterilisation, to periodic abstinence or lactational amenorrhea (the temporary infertility that can occur when a woman breastfeeds). Indeed, family planning is often used in the public lexicon as synonym for ‘contraception’, even though the phenomenon has far more expansive meanings.2
A final note on my definition of the field concerns the so-called ‘targets’ of family planning programmes – the people to whom contraceptive development and programming have been almost entirely directed. Of course, both women and men are involved in creating and preventing pregnancies. However, despite some longstalled efforts on methods for men, contraceptives are overwhelmingly made for women’s bodies, and pregnancy prevention has long been seen as women’s domain (Watkins 1993). For the most part, the field portrays men as either uninterested in or incapable of participating in family planning in the same way as women. In many ways, this approach both reflects and perpetuates larger socially held beliefs about gender, sexuality and responsibility. For example, men’s stronger and allegedly unchangeable sex drives undermine contraceptive efforts, whereas women’s supposed greater sexual responsibility and relative lesser interest in sexual pleasure translate into contraceptive accountability.
On that note, I want to turn to examples of how the field’s current framing of sexuality fails to acknowledge how contraceptive use is influenced by women’s seeking of sexual enjoyment. Take, for example, the behavioural models used to explain women’s contraceptive practices. Given that one of the field’s central goals is to avert unwanted pregnancies, family planning practitioners are intent on understanding what helps explain contraceptive use (or non-use), method preference and continuation. The field’s current behavioural models of contraceptive practices suggest that a woman’s choice and consistent use of a particular method are related primarily to access, effectiveness, ease of use and the woman’s desire to limit births. Models rarely consider how methods either enhance or detract from the sexual experience, even though methods are designed specifically for use during sex.
A lack of sex positivity also exists in the behavioural models used to explain unintended pregnancy.3 The prevalence, health consequences and political salience of unintended pregnancy have made it a source of significant policy concern for several decades. Worldwide, an estimated 80 million of the 210 million pregnancies each year (approximately 40 per cent) are unplanned (WHO 2004), and the average woman will have at least one abortion in her lifetime (AGI 1999). In the USA, nearly half (48 per cent) of all pregnancies are unintended, giving the country one of the highest unintended pregnancy rates in the industrialised world (Finer and Henshaw 2006; Henshaw 1998). Most unintended pregnancies are caused by lack of contraceptive use, not by contraceptive failure (Henshaw 1998; Trussell et al. 1999). Current explanations for non-use generally pertain either to women’s knowledge of or access to contraceptive services (or lack thereof), or gender-based power imbalances in sexual relationships, which can render women unwilling or unable to negotiate for contraceptive use with their male partners (Brown et al. 1995). Few family planning researchers have examined whether unprotected sex or pregnancy ambivalence may heighten sexual experience, or whether the romantic notion of creating a child with someone may deter contraceptive use. We know little about the emotional, physical and cognitive states that contribute to situations in which lack of contraceptive use is pleasurable or purposeful to women and men.
This dearth of sexuality in explaining unintended pregnancy is more striking when we compare it to research on men in parallel areas of public health. For example, the HIV/AIDS literature has examined ways in which sexual pleasureseeking may sometimes motivate HIV risk taking among men who have sex with men (Dowsett 1996: Parker 1999; Parker et al. 2000). Deliberately unprotected anal sex, or barebacking, may be eroticised among certain men who have sex with men, even those who may be well aware of the attendant risk of HIV (Díaz 1999; CarballoDieguez and Bauermeister 2004; Shernoff 2005; Junge 2002). In some circumstances, riskier sex may be hotter or closer than protected sex; some men may also desire to share a disease with a loved one in order to facilitate closeness or connection. An unintended pregnancy is likely to carry even more potential for closeness, affirmation and connection. Yet we know next to nothing about how desire for a pregnancy or conception, even when a child is not wholly intended or wanted, shapes contraceptive practices.
Neither have individual contraceptive methods been studied or explored extensively for their effects on sexual experience, or how such sexual effects shape the ways in which people use these methods.4 Hormone-based contraceptives (which include the pill, the patch, the ring, injectables), which are the most widely used reversible methods in many parts of the world, have not been systematically assessed for how they affect women’s sexual pleasure, lubrication or ability to achieve orgasm.5 Contraceptive researchers have thoroughly documented hormonal methods’ effect on ovulation. Far fewer have demonstrated their effects on the peak in sexual interest that many women experience during ovulation (Anderson-Hunt et al. 1996; Dennerstein 1996).
In attention to the sexual aspects of hormonal methods for women is even more striking with juxtaposed to the attention afforded to sexuality within the arena of hormone-based methods under development for men. Research on male-based methods is strongly marked by concern for their effects on libido, sex drive and sexual functioning (Solomon et al. 2007; WHO 1982; Oudshoorn 2003). Contraceptive developers implicitly recognise that men’s uptake of these new methods will be limited if their ability to experience pleasure is compromised.
Women’s potential sexual resistance to male condoms has also been relatively unexplored. Family planning programmes, as well as HIV/AIDS and public health programmes more generally, often rely on women to ensure that male condoms are used, even though women do not wear male condoms. Research indicates that women may lack the power to press for condoms (Amaro 1995; Amaro et al. 2001; Worth 1989; Blanc 2001; Exner et al. 2003), and that even when women are able to negotiate for condom use, they may be disinclined to do so out of desire for sex that seems loving, trusting and intimate (Sobo 1995; Hirsch et al. 2002). However, we know relatively little about women’s sexual experiences with male condoms, or how their condom practices may be shaped by sexual preferences or changes in sexual sensation enjoyment. In contrast, family planning research tends to assume that many men do not like using condoms because they curtail sexual sensation (Crosby et al. 2004; Thomsen et al. 2004; Khan et al. 2004; UNAIDS 2000) and that many men dislike using condoms – or outright refuse to wear them – because they reduce sexual pleasure (UNAIDS 2000).
Given that a sex-positive approach has been largely absent from contraceptive research, development or acceptability studies, it is no surprise that it also rarely features in contraceptive market and programming. Contraceptive advertisements and promotional materials tend to adhere to the rational actor model used frequently in public health, in which women supposedly weigh the economic and health costs and benefits of various methods in making their contraceptive choice. Sexual benefits or detractions are rarely, if ever, included on these materials. Pamphlets and advertisements tout methods’ efficacy, convenience and non-contraceptive benefits (e.g. acne improvement or menstrual lightening), but not their contribution to or reduction of enjoyable and exciting sex.
Undoubtedly, sexual stereotypes fuel some of the pleasure deficits and sexual double standards outlined earlier. Family planning discourse stems from a larger cultural model in which men’s greater sexual ‘needs’ and desires allegedly dictate that men cannot or will not take responsibility for preventing pregnancy, whereas women stereotypically have the ability to be more sensible and responsible – perhaps due to their comparatively lesser sex drives (Tolman and Diamond 2001). The current family planning approach to sexuality is also consistent with a number of other prevailing policy discourses (e.g. sexual trafficking, child marriage and women’s rights in Afghanistan and Arabic countries), which describe women as sexual victims rather than sexual agents and men’s sexual behaviour as out of control or unchangeable (Girard 2004). However, some far more well-intentioned roots also underlie the pleasure deficit.
To start, it may be nearly impossible to devise a suitable universal definition for healthy, pleasurable sexuality, given the deeply personal nature of sex and myriad cultural and social influences on sexual desires, meanings and behaviours (Parker and Aggleton 1999). In other words, it may be more straightforward, as well as more pressing, for family planning researchers and policymakers to define threats to women’s sexuality than to operationalise those factors that maximise sexual enjoyment. This distinction between ‘freedom from’ phenomena such as violence and sexual assault and ‘freedom to’ healthy, happy sex lives has been noted by Rosalind Petchesky, who calls for a distinction between ‘negative’ (freedom from) and ‘positive’ (freedom to) sexual rights (Petchesky 1990; Petchesky et al. 1998).
A focus on negative sexual rights can be traced back to the earliest debates about modern birth control in the USA and England. Whereas today we consider access to contraception and abortion inextricably linked with feminism, many western feminists in the early 1900s were against contraception (Smith 1997; Gordon 1984). A number of bourgeois Victorian women’s advocates viewed birth control as only leading women to further sublimate themselves to men’s sexual desires (Banks 1981). In this context, contraception would give women less opportunity to avoid unwanted sexual contact and was a step away from bodily integrity and social emancipation.
Contraception was also feared to contribute to more philandering on men’s behalf. In bourgeois western sectors at this time, sex was not thought of as especially enjoyable for socially privileged women (D’Emilio and Freedman 1988; Weeks 1981/1989). Several years later, even after concept of ‘voluntary motherhood’ had gained widespread feminist appeal, Margaret Sanger and her colleagues continued to distance themselves from the sexual aspects of birth control, even though sexual emancipation may have been an underlying goal of many feminists of the time, including Sanger herself (Tone 2001).6 To win medical, governmental and public approval, feminists and neo-Malthusians emphasised birth control’s ability to reduce maternal mortality and morbidity, slow the increase of poor and immigrant populations and ‘strengthen the family as a unit rather than to free women ’ (Dixon-Mueller 1993a: 42, emphasis in original). Indeed, particularly as feminists tried to enlist clinicians and policymakers to their cause, they were forced to emphasise the ways in which contraception could control rather than liberate sexuality.
Many decades later, women’s rights advocates continued a focus on negative versus positive rights in relation to family planning. Beginning in the 1970s, feminists across the globe rallied against western countries’ efforts to control population growth in developing countries; they argued that these policies and programmes were so intent on declining birth rates that they often vanquished women’s individual rights to use or not use contraception as they wished (Dixon-Mueller 1993a; Connelly 2008). To convince population planners to change their tactics, some feminists argued that one of the best ways to encourage smaller families was to help women achieve social and sexual autonomy. A new body of research was born, documenting how threats to women’s sexual self-determination could undermine their ability to prevent pregnancies.
Thus, recent decades have witnessed a surfeit of work on negative sexuality in the family planning field – how threats to women’s sexual wellbeing can undermine larger family planning goals, as well as (more recently) the prevention of HIV transmission. Feminist researchers have documented how gender-based violence (McCarraher et al. 2006; Pallitto and O’Campo 2004; Watts and Mayhew 2004; Stephenson et al. 2006; El-Bassel et al. 2005), non-volitional sex (Kalmuss 2004; Doyal 1995) and relationship power imbalances (Pulerwitz et al. 2002; Blanc 2001) can all sabotage women’s self-determination. In turn, the violation of women’s sexual rights contributes to high rates of unintended pregnancy, HIV transmission and other forms of reproductive morbidity and mortality (Finkler 1994; Doyal 1995).
Thus, the family planning field has long been marked by a focus on negative versus positive sexual rights for women, even among those constituencies fighting for gender equity. And to be sure, a sex-positive family planning agenda may be a far less important feminist, social justice agenda item compared to issues such as clean water, poverty reduction or deleterious globalisation policies and development practices. Some feminists have also warned that a focus on pleasure may also inadvertently perpetuate gender inequality. At least one scholar has cautioned against the promotion of a universal human right to pleasure, arguing that men’s demands for sexual pleasure could infringe on women’s basic sexual rights (Oriel 2005).
Despite these cautions, a growing body of work indicates the importance of pleasure not only as an end in itself, but also as a critical part a complete understanding of sexual and reproductive behaviours. In this concluding section, I highlight some of the studies that show the importance of sex-positive work and suggest some new framings for the future of the field.
Some investigations have examined contraceptive influences on sexual functioning, with results suggesting that women’s contraceptive behaviours are shaped by sexual acceptability and side effects. In a longitudinal study of new oral contraceptive users in the USA, for example, researchers found that a decrease in women’s libido and sexual enjoyment was strongly associated with discontinuation (Sanders et al. 2001). In a study of the features most likely to shape contraceptive method choice, women ranked ‘lack of interference with sexual pleasure’ as a ‘very important consideration’ as often as men did (30 per cent of men and 28 per cent of women) (Grady et al. 1999).
Similarly, in qualitative research on sexual pleasure and contraceptive use, the way contraceptives altered ‘sexual aesthetics’ (sensation, libido, lubrication, spontaneity and other sexual attributes) mattered to women and men equally and shaped both the choice of method and manner of use (Higgins and Hirsch 2008). However, gender and power influenced these aesthetics in striking ways. For example, women often disliked male condoms because they diminished their partner’s pleasure, and thus their own. Women were often concerned about the sexual side effects of male condoms for their partners, whereas men expressed comparatively little concern about the sexual side effects of women’s methods.
Indeed, burgeoning scholarship demonstrates a small but growing awareness that the ways male condoms feel sexually matter to women as well as men, often in gendered ways. One qualitative study from the UK (Holland et al. 1998) explored women’s sexual experiences with male condoms, with attention to the pressures put on young men and women to conform to gender-appropriate sexual behaviours. In both this latter study and in a quantitative analysis of women at risk for HIV in New York City (Ehrhardt et al. 2002), those women who felt that condoms undermined their sexual pleasure were less likely to use them than women who did not report condom-related reductions in pleasure.
There have also been attempts to theorise and demonstrate pregnancy-associated pleasures and how they can stymie effective contraceptive use, even in the absence of desire for a child. At least one preliminary study has suggested that in the heat of the sexual moment, a couple’s or individual’s temporary desire for a pregnancy could lead to unprotected sex, even if a baby were not fully or rationally intended (Peacock et al. 2001). Likewise, US abortion clinic clients have sometime described a temporary surrender to the fantasy of a pregnancy (Higgins 2007). My own work has begun to explore the degree to which women and men find pleasure in the possibility of a pregnancy with a particular partner or at a particular moment, and how this can undermine contraceptive use (Higgins et al. 2008). For some respondents in this study, sex occasionally became a way to flirt with and eroticise pregnancy risk, often as an avenue for seeking ultimate closeness with one’s partner. Aroused during sex by the idea of pregnancy, these respondents dispensed with contraceptives.
This study and others have also demonstrated a less direct, less strongly erotic relationship between pregnancy ambivalence and lack of contraceptive use. In some situations, although pregnancy is neither intended nor not intended, the notion of creating a baby can be compelling – a situation that could contribute to inconsistent contraceptive use (Higgins et al. 2008). This finding echoes the work of Stanford and colleagues, who have used the term ‘passive procepting behaviour’ to describe fecund couples who do not use contraceptives but are not trying to conceive (Stanford et al. 2000: 185). Along similar lines, one study of women found that half of coital events were unprotected, even among those respondents who reported they were committed to not getting pregnant (Bartz et al. 2007). Day-to-day factors such as respondents’ daily assessments of partners’ support and feelings of being in love could help predict lack of contraceptive use. Feeling loved and supported are two social benefits that can carry great weight in the heat of the sexual moment.
Taken together, the studies mentioned here indicate that pleasure seeking influences the ways in which contraceptives are used or not used. They suggest that, without a better understanding of how people seek sexual enjoyment, we will fail to have a complete picture of reproductive behaviours.
In particular, the last studies create the groundwork for a new framework that considers the ways in which unprotected sex can meet people’s sexual, emotional and social needs, including sexual arousal and fulfilment, closeness and connection with their partner and a more emotionally and materially secure future. Given the existence of these needs, intermittent or nonexistent contraceptive use – practices that are consistently portrayed in the family planning field as failure to do something, an ‘unmet need’ for family planning or a health risk that rational people would want to avoid – may instead represent purposeful action.
One hopes that these studies are not so much exceptions to the field’s pleasure deficit as much as harbingers of things to come. In constructing a new sexual frame for itself, the family planning field should continue to dispense with the rational actor model and consider myriad reasons why people engage in the sex that leads to pregnancy in the first place. Researchers and practitioners should attend to the ways in which both women and men’s desires influence the ways in which sex happens, and thus, the ways in which pregnancies are either created or prevented. Finally, the field’s most basic premises should build from the assumption that the way sex feels matters to women and, as a result, shapes contraceptive practices. Recognising and addressing the positive sexual aspects of people’s lives will help us better understand and address not only people’s risk behaviours, but also their wellbeing more generally.
1 For a small sampling of family planning and demographic literature that speaks of sex in this way, see Ali et al. 2003; Montgomery et al. 1998; Spira et al. 1985; Léridon 1977. Thanks to Susan Watkins (1993) and Jennifer S. Hirsch for bringing this issue to my attention.
2 For example, one could argue that ‘family planning’ encompasses communication between couples about their desired family size or the reproductive choices of those who cannot or chose not to have children through heterosexual intercourse – for example, gays, lesbians or infertile heterosexual couples who wish to become parents.
3 There is a great deal of disagreement on the definition of, precursors to, and even the usefulness of the concept of pregnancy ‘intendedness’. For example, women often report being happy about an unintended pregnancy, and one-third of pregnancies resulting from contraceptive failures are subsequently classified as intended (Klerman 2000; Trussell et al. 1999). Despite these definition controversies, the pervasiveness of unsafe abortion worldwide serves as one persistently strong case for the social and health costs of unintended pregnancy for women.
4 I should note the two exceptions to this statement: both microbicides and the female condom have been explored much more fully than other methods in terms of their sexual dimensions. But both of these methods emerged from efforts to create female-controlled HIV prevention strategies rather than from within the family planning field.
5 Studies have been conducted of oral contraceptives’ effects on women’s libido, with decidedly mixed results (Davis and Castano 2004; Schaffir 2006; Gambrell et al. 1976). Some women report diminished sexual interest while taking the pill, whereas other women report no change or even increases in sexual interest.
6 Often and unfortunately, feminists also adopted popular eugenicist and racist arguments to further their cause – that is, suggesting that birth control could be used to control growing populations of African Americans and Irish, Italian and Jewish immigrants (Gordon 1976).
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